This document was created following the publication of the Planetree and National Academy of Medicine (NAM) discussion paper summarizing the evidence for patient and family engaged care (PFEC). One of my and the CT Center for Patient Safety’s focused efforts to improve patient safety is to support a culture where patient priorities care, patient and family engaged care, patient centered care is the norm and not the exception. The original paper, Harnessing Evidence and Experience to Change Culture: A Guiding Framework for Patient and Family Engaged Care can also be downloaded.

The Connecticut Health I-Team just released an article, 14 Hospitals Penalized For Infection Rates, Injuries, bringing attention to Connecticut hospital's infection rates. As part of the Centers for Medicare and Medicaid Services’ (CMS) Hospital-Acquired Condition Reduction Program, fourteen of thirty-one Connecticut hospitals were penalized for being among the nation's lowest performers in terms of their relatively high numbers of patient hospital aquired infections, other avoidable hospital injuries and also antibiotic-resistant bacterial infections.

We are hearing so much about health care harm lately. ECRI has identified their Top 10 Patient Safety Concerns for Healthcare Organizations. In a recent article, Report: IT Systems, Patient ID Errors, Top Issues For Health Care Organizations, C-HIT has delved into this issue to examine at how it impacts Connecticut. What can we do with lists like this one? Read the article to see what thoughts Lisa Freeman of CTCPS has to share.

Watch Jean Rexford’s February 10, 2016 interview with Eric Parker,WFSB's iTeam Investigative reporter. The discussion centered on the recently released CT Adverse Event report which addressed a total of 471 reports of adverse events in Connecticut 2014. Included are 15 wrong site surgeries, 4 wrong surgical procedures performed and 24 instances of foreing objects being left in the patient after surgery amongst many others. In the published report this year is a new section, “a patient-initiated voluntary online survey of adverse medical events: the perspective of 696 injured patients and families,” bringing the patient voice into the report. The CT State report can be seen at: http://www.ct.gov/dph/lib/dph/AdverseEventReport2015.pdf.

A major state law passed last year aims to change that, with a host of transparency provisions that begin rolling out this month. They’re aimed at making it easier for patients to learn the cost of their medical care ahead of time, including any charges they might face if they seek care outside their insurer's network. You can learn more at How well will new rules on health care cost transparency work? Lisa Freeman recently tried to learn the cost of a diagnostic test before this law went into effect - that didn't go so well.

When I was recently in the hospital, I was not able to focus on all of the strategies that I regularly teach others to follow. But above all else, I knew to have a family member there with me to be my advocate. This CT Mirror article, 9 Things All Hospital Patients Should Know, shares the thoughts of many experts on strategies and tools that you can use if/when you are in the hospital. Please read and share it!! It could save a life!

On December 2nd I presented the keynote speech at the Hartford Business Journal Health Care Heroes Award Luncheon. The subject was patient-centered care, a topic that I am very passionate about. Following that presentation, I was asked by the Universal Health Care Foundation of Connecticut to write a guest blog for them based on my presentation. By following the link, you can read the blog on their site.

According to an article in the CT Post, Fewer errors reported by hospitals, but worries remain, the CT DPH Report of Adverse Events is out and the news is that things have improved in a few areas, and gotten worse in several as well. Just as troubling is that the incidence of these adverse events — which include falls, surgical errors and pressure ulcers — remained higher than in 2012. Our state's hospitals are not moving the needle that much and people are still being harmed in events that should never have occurred.

In July of 2015, ProPublica published a new tool called the Surgeon Scorecard to provide patients with newly available information in a useful format to help to evaluate surgeons. Through the tool, readers can look up surgeons by their location, a specific hospital or by the surgeon's name. This will allow comparisons between surgeons who do the same procedure within a hospital or within a locale. Read Trend CT’s article, A tool to see your surgeon’s complication rates to learn more.

With providers moving to electronic medical record systems, they often still don't "talk" to each other. Just think how much safer your care could be if all of your providers could see the same complete data and know what each other is doing. There would be less duplication of testing, everyone would be on the same page, and we would expect that much less information would fall through the cracks. Read Lisa Freeman's comments in this CT Mirror article, Can the state build a better system to get your medical records to your doctors?.

The current legislative session in Hartford holds promise for improving the safety and quality of health care in Connecticut. There are a number of bipartisan bills introduced by Senator Looney and Senator Fasano, as well as other Senators that call for transparency of infection rates, health care costs, prices and quality information as well as a bill to allow for dispute resolution of surprise billing and emergency services. You can read Lisa Freeman's Op-Ed in the CT Mirror regarding the proposed legislation here.

This CT Post article discusses the concerns raised related to outpatient clinics, also known as ambulatory care centers, which are emerging as an increasingly popular place for patients to seek treatment. Recently, there have been concerns raised about their safety as is discussed in the article, Suit raises concern about outpatient clinics.

The Public Health Committee of the Connecticut General Assembly held a hearing on March 11th for public comment on a number of bills to address the changing health care landscape in Connecticut. Some of the bills address the need for transparency of cost and quality; a theme that has broader support among different stakeholders. In the CT Mirror's article, In controversial health care bills, some agreement on transparency, Jean Rexford shares her thoughts on the need that Connecticut residents have for this information to be available so that they can be more informed and engaged in their healthcare.

Patient-Centered Care involves healthcare systems embracing a culture and a philosophy that includes and considers patient's perspectives in everything that they do. Lisa Freeman wrote an article for Planetree's Planetalk publication titled: A Call to Action: It's Time to Break Another Glass Ceiling. In it, she talks about the missed opportunity when hospital, long-term care facilities and physician practice governing boards do not have patient members on them. After all, this represents the ultimate partnership with patients and their perspective should become part of business as usual.

Given all of the current technology, strategies and tools that are available to prevent these occurrences, it is unacceptable that foreign objects are still being left in surgical sites and that wrong-site surgeries are still occurring," says Lisa Freeman, executive director of the nonprofit Connecticut Center for Patient Safety. Laura Landro's article in the Wall Street Journal, How to Make Surgery Safer, points out that there are still 4,082 malpractice claims for mistakes that should never occur such as operating on the wrong body part. She also discusses various strategies that are working in Connecticut hospitals and others across the country to reduce errors and bring about improvements in healthcare outcomes and quality.

Jean Rexford recently spoke with Eric Parker, Chief Investigative Reporter for the Channel 3 I-Team (WFSB). His report on hospital acquired infections, including his conversation with Jean was aired on November 3rd, in two segments. If you were unable to watch it when it aired, the links to the two-part report on Connecticut's WFSB Channel 3 are: Part I and Part II

Following the November release of the CT state infection report and the January release of the state’s Legislative adverse events report, CTCPS Executive Director Lisa Freeman’s op-ed, CT hospitals must do more to prevent errors and patient harm, was published in the CT Mirror on January 14, 2015. The results of these reports show that Connecticut’s hospitals are performing very badly. CT ranked 50th with the highest percentage of hospitals of any state exceeding the infection standards set by the U.S. Centers for Disease Control and Prevention. The rate of adverse events reported also increased over the prior year with wrong site surgeries and retained foreign objects - known as "never events" still occurring in our hospitals.

With Kaiser's announcement that 721 hospitals in the United States will witness cuts in their Medicare payments by 1 percent due to their high rates of hospital-acquired conditions, Jean Rexford has been called upon for her expert opinion by several media outlets. The stories where she shared her thoughts can be found in the National Monitor's story, Funding for U.S. hospitals steadily declining and in the CT Post's story, High infection rates may mean funding cuts.

Under a grant from the CT Health Foundation, CTCPS researched the barriers that Connecticut’s newly insured are facing in obtaining health insurance and medical care. We recently met with the editorial board at the Hartford Courant and this November 12, 2014 editorial is the outcome of our shared information. Click here to view the full report.

Jean Rexford recently spoke with Eric Parker, Chief Investigative Reporter for the Channel 3 I-Team (WFSB). His report on hospital acquired infections, including his conversation with Jean was aired on November 3rd, in two segments. If you were unable to watch it when it aired, the links to the two-part report on Connecticut's WFSB Channel 3 are: Part I and Part II

We are excited to share the official launch of The Connecticut Partnership for Patient Safety (CPPS). This collaborative endeavor has set its focus on patient protection and patient safety by reducing patient harm caused by the State’s healthcare delivery system through collaborating with and enhancing the many patient safety/quality improvement initiatives already underway. Jean Rexford, representing the patient voice, sits on the Board. Read the full press release here.

On May 14th the Connecticut Center for Patient Safety (CTCPS) hosted a Roundtable Panel discussion, made possible by a generous grant from the CT Health Foundation, with national and state experts to learn more about the experience of Connecticut's newly insured. It was a tremendous success and generated rich and multi-faceted discussions about the current issues facing this population. More about the event can be read in an article published by the CT Mirror, Obamacare got them insurance, but patients still face barriers to care. What we learned will be combined with extensive research to ultimately empower Connecticut's newly insured by identifying and finding ways to close the gaps in accessing health care.

There are databanks that track bad doctors. The National Practitioner Databank and the Healthcare Databank were created for this purpose. Recently, the Connecticut Supreme Court rendered a decision in which the justices ruled that neither database can be accessed by the public under freedom of information laws. As Jean Rexford points out in an article titled "The Case Of The Doctored Sperm Donation," it is good that these databanks give "hospitals and medical schools access to the physicians' histories, for hiring purposes". But she goes on to state that "medical consumers should be able to access similar information."

February 4, 2014, Today’s guest post on the Connecticut Health Foundation blog was written by Jean Rexford, Executive Director of the CT Center for Patient Safety. "How can so many bright people not see what I see? Years ago, a PBS special featured how different animals and birds saw the world through their unique set of eyes. Eagles, chameleons, houseflies have a unique lens that allow them to see what they need to so that might survive in a complex world. I think of this often as I sit at multiple tables, in Connecticut and on national committees. Why don’t the other people at the table know what I know?" Read more.

Listen to CTCPS Executive Director, Jean Rexford's recent interview on WTIC's "Face Connecticut" hosted by Sam Gingerella which aired Sunday morning, November 17th. In this discussion, Jean talked about the changing face of hospital care, infection rates and other medical harm, the patients’ role and voice in healthcare, and how CTCPS is engaged in representing and protecting the patient on a local and national level.

This article, 10 Tips for a Better Hospital Stay in October's Healthylife magazine, to which Jean Rexford has contributed and is quoted in, talks about 10 steps you can take to better anticipate and prepare for a trip to the hospital. Taking an active role in your care can help to ensure a positive hospital experience. With some smart preparation, you can feel confident that you've done your best to create a situation that will lead to a speedy and healthy recovery.

An article, State's Doctor Discipline Process Hampered by Delays, authored by journalists Colleen McKown and Lisa Chedekel, in which Jean Rexford is quoted, can be found in both the CT Post and on the C-Hit Websites. It discusses the profound delay from the time that a complaint is filed about medical care and the time that a disciplinary decisions is rendered can range from one year to as long as four years. During this delay, the provider continues to practice.

The State of Connecticut is currently engaged in the development of a database that will consolidate – for the first time – data for health encounters across every provider, facility, plan, and health claim payer. The All Payer Claim Database (APCD) is the federally funded underpinning for evidence-based reforms that can influence economic and equity analysis, health systems quality and outcomes benchmarking, and consumer transparency. This is an important project of inestimable value to our state. Looking at information gathered from ten states have already established APCDs, we endeavored to translate what we learned into recommendations for consideration in our state. Our findings, in a study done by Jean Rexford, Ellen Andrews, PhD and Brenda Shipley, MA can be read here.

Jean Rexford is quoted in this C-Hit article titled Hospitals Mobilize To Tackle Alarm Fatigue which discusses the phenomenon known industry-wide as alarm fatigue where medical devices with built-in alarms – such as heart monitors, infusion pumps and ventilators – designed to alert caregivers that patients are in danger could potentially put patients at risk because caregivers are desensitized by the sheer number of alerts and false alarms.

Disclosure and Apology: A Win-Win for Patient Safety and Medical Liability? On July 28, 2014, Jean Rexford participated in a discussion about medical liability reform and how to protect patients who experience adverse medical events and help practitioners provide the highest quality care possible. Their discussion was moderated by the Alliance for Health Reform, included representatives from various stakeholder groups and can be viewed here.

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Becoming a More Empowered Patient

First, we have chosen to share a video by Consumer Health Choices: Talking With Your Doctor. In it you will see how preparing for you appointment can make a difference.

We have chosen a second video by the National Patient Safety Foundation: AskMe3, to share with you. Here, you learn that there are three important questions to ask your doctor whenever you see him or her.